Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evenglow Lodge during CMS and state inspections, most recent first.
The facility failed to store medications properly, mixing them with food in the medication room refrigerator. Medications for several residents, including insulin and suppositories, were found alongside food items, and some lacked proper labeling. Additionally, a Lantus pen for a non-resident was mistakenly stored, indicating a pharmacy delivery error.
A resident with moderate cognitive impairment experienced a fall during a staff-assisted transfer, resulting in a toe fracture. The incident was not reported to the resident's family or physician until the following day, contrary to the facility's procedures. The Director of Nursing confirmed the lapse in reporting, and the nurse practitioner was unaware of the incident until evaluating the resident for toe swelling and bruising.
A resident with moderate cognitive impairment and chronic dry eyes did not receive adequate personal hygiene assistance, resulting in persistent eye redness and discharge. Despite receiving daily eye drops, the resident experienced discomfort, and staff failed to consistently wash the resident's eyelids with a warm washcloth as part of morning care.
The facility failed to implement fall prevention interventions and timely obtain an X-ray for two residents, leading to deficiencies in care. A resident with a fractured hip experienced a delay in receiving an X-ray, while another resident's fall and resulting toe fracture were not documented or assessed immediately. Staff interviews revealed issues with accessing fall interventions and reporting incidents.
The facility failed to label and properly store respiratory equipment for two residents. One resident's nebulizer mask and tubing were left uncovered and undated, contrary to facility policy. Another resident's oxygen tubing was not labeled with a date, despite requirements for weekly changes. These deficiencies were confirmed by staff observations and interviews.
A facility failed to conduct an initial assessment before starting an antipsychotic medication for a resident with multiple diagnoses, including Alzheimer's and psychosis. The facility's policy requires an assessment to determine underlying causes of behavior before medication use, but this was not done. The resident began Seroquel without the required assessment, and the first relevant assessment occurred nearly a month later. The DON confirmed the oversight.
A volunteer at the facility failed to wear gloves while handling a resident's turkey burger, contrary to the facility's policy requiring gloves for ready-to-eat foods. The Dietary Manager confirmed the necessity of glove use in such situations.
The facility did not post daily staffing information, including total hours worked, affecting all 30 residents. The DON confirmed the absence of this information on the bulletin board, and the Scheduler admitted to not posting it for September 2024, unaware of the requirement to include hours worked. The staffing report lacked total hours worked for licensed and unlicensed staff.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to adhere to proper medication storage protocols, as observed during a survey. Medications belonging to four residents were stored improperly in the medication room refrigerator, alongside food items such as pudding cups, applesauce, and nutritional drinks. The medications included insulin, suppositories, and ophthalmic drops, some of which lacked proper labeling. Additionally, a Lantus pen intended for a non-resident was found in the refrigerator, indicating a possible pharmacy delivery error that had not been rectified since July 2024. The facility's Medication Storage Policy mandates that medications and biologicals be stored in a locked cabinet or medication room, separate from food. However, this policy was not followed, as confirmed by the registered nurses and the Director of Nursing. The presence of food with medications and the unidentified Lantus pen in the refrigerator highlights a significant lapse in maintaining the integrity and security of medication storage, affecting the care of the residents involved.
Failure to Timely Report Resident Fall Incident
Penalty
Summary
The facility failed to report a fall incident involving a resident with moderate cognitive impairment to the resident's physician and family representative in a timely manner. The incident occurred when the resident was lowered to the floor during a staff-assisted transfer, resulting in the resident's left foot sliding underneath a recliner. The fall was not reported to the resident's family until the following day, and the nurse practitioner was also not informed until the resident was evaluated for toe swelling and bruising. The facility's procedure for reporting falls and incidents was not followed, as the agency nurse and CNA did not report the fall. The resident's medical records lacked documentation of immediate notification to the family and physician, which was confirmed by the Director of Nursing. The resident later complained of toe discomfort, and an x-ray revealed an acute non-displaced fracture of the left great toe. The nurse practitioner stated that they were not aware of the incident until the evaluation for the toe injury, highlighting a communication gap with agency staff. The facility's occurrence report to the state agency was also delayed, further indicating a deficiency in the facility's incident reporting process.
Failure to Provide Adequate Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate personal hygiene assistance to a resident with moderate cognitive impairment who requires partial staff assistance for personal hygiene. The resident was observed with red lower eyelids and green discharge in the corner of the left eye after breakfast, and later with white/yellow drainage on the eyelids during a resident council meeting. The resident reported receiving daily eye drops but continued to experience eye discomfort and redness. A nursing note documented the resident's complaint of eye discomfort and increased redness, with a warm compress applied. A registered nurse acknowledged that the resident's eyelids should be washed with a warm washcloth as part of morning care, but this was not consistently done. A nurse practitioner noted the resident has chronic dry eyes and discharge related to allergies.
Failure to Implement Fall Prevention and Timely Medical Assessment
Penalty
Summary
The facility failed to implement fall prevention interventions and timely obtain an ordered X-ray for two residents, leading to deficiencies in care. Resident R13, diagnosed with a fractured right hip, Alzheimer's dementia, and other mobility issues, was at moderate risk for falls. On 7/30/24, R13 slid off the bed and complained of hip pain. Despite orders for bilateral hip X-rays, there was a significant delay in obtaining the imaging, which was not completed until late in the evening. The X-ray revealed a possible fracture, and R13 was subsequently transported to the hospital for further evaluation. Resident R12, with moderate cognitive impairment and high fall risk, experienced a fall on 5/5/24 that resulted in a toe fracture. The fall was not documented in the medical record, and there was no immediate assessment for injuries. Additionally, R12's care plan included the use of a nonskid mat in the wheelchair, which was not in place at the time of observation. The fall was not reported until the following day, and the post-fall assessment was not documented by the agency nurse on duty. Interviews with staff revealed issues with accessing fall interventions and delays in reporting incidents. The Director of Nursing confirmed the lack of documentation and timely assessment for R12's fall. The facility's failure to adhere to fall prevention protocols and timely medical assessments contributed to the deficiencies identified during the survey.
Failure to Label and Store Respiratory Equipment
Penalty
Summary
The facility failed to properly label and store respiratory care equipment for two residents, leading to deficiencies in their care. For one resident, diagnosed with multiple respiratory conditions including chronic respiratory failure and COPD, the nebulizer mask and tubing were observed hanging on a drawer handle without any protective covering or date label, indicating when they were last changed. This was noted over several days, despite the facility's policy requiring weekly changes and proper storage in a plastic bag. Another resident was observed using oxygen via a nasal cannula connected to a portable oxygen tank, with the tubing not labeled with a date. A Licensed Practical Nurse confirmed that the oxygen tubing should be changed weekly and labeled, but upon inspection, it was found that the tubing was not dated. The resident's treatment administration record indicated that the tubing and humidifier should be changed weekly on a specific day, which was not adhered to.
Failure to Conduct Initial Assessment Before Antipsychotic Medication
Penalty
Summary
The facility failed to complete an initial assessment before starting an antipsychotic medication for a resident, identified as R28, who was reviewed for unnecessary medications. The facility's policy requires staff to determine if there is an underlying cause for behaviors before considering antipsychotic medication, and to complete a pre-psychoactive medication assessment form. However, this assessment was not completed for R28 prior to the initiation of Seroquel, an antipsychotic medication, on June 17, 2024. R28's medical records indicate diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Alzheimer's Disease with Late Onset, Dementia, and Unspecified Psychosis. Despite these conditions, the first psychotropic medication and behavior assessment that included Seroquel was not conducted until July 10, 2024, nearly a month after the medication was started. The Director of Nursing confirmed the absence of the initial assessment, acknowledging that it should have been completed before the medication was administered.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to ensure food was handled in a sanitary manner, as observed during a meal service on the second floor. A volunteer, who was assisting staff in serving meal trays, touched a resident's turkey burger bun with bare hands while applying ketchup, contrary to the facility's policy on glove use. The policy mandates wearing gloves when handling ready-to-eat foods. The volunteer confirmed that he only wore gloves when prepping chicken on the bone and did not wear gloves when handling the turkey burger. The Dietary Manager later confirmed that gloves should be worn when handling ready-to-eat foods.
Failure to Post Complete Daily Staffing Information
Penalty
Summary
The facility failed to post daily staffing information, including the total hours worked, which affects all 30 residents residing in the facility. On the morning of September 5, 2024, the Director of Nursing (DON) confirmed that the bulletin board by the first-floor nurse's station did not contain the required daily staffing information. The DON stated that the Scheduler is responsible for posting the staffing information, but the forms provided did not include the total hours worked for both licensed and unlicensed staff. The Administrator acknowledged that there should be a form that includes the hours worked. The Scheduler admitted to not posting the daily staffing for September 2024 and was unaware that the hours worked needed to be included. The provided staffing report for September 2024 documented the number of full-time employees for each shift but did not include the total hours worked.
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What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pontiac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accolade Healthcare Of Pontiac | 0.7 mi | ★★★★★ | 4 | 0 |
| Goldwater Pontiac Nursing Home | 2.7 mi | ★★★★★ | 7 | 0 |
| Fairview Haven | 10.6 mi | ★★★★★ | 0 | 0 |
| Flanagan Rehabilitation And Health Care Center | 14.8 mi | ★★★★★ | 3 | 0 |
| Arc At Dwight | 18.2 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.